ARC Journal of Gynecology and Obstetrics Volume 4, Issue 1, 2019, PP 21-23 ISSN 2456-0561 DOI: http://dx.doi.org/10.20431/2456-0561.0401004 www.arcjournals.org Hydrosalpinx and IVF: Effect and Management Akmal El-Mazny, MD, FICS* Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University, Egypt *Corresponding Author: Akmal El-Mazny, MD, FICS, Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University, Egypt, Email: [email protected] Abstract : Patients with a hydrosalpinx have been found to have significantly poorer IVF outcome than do patients with tubal factor infertility but no hydrosalpinx. The exact mechanism by which hydrosalpingial fluid impacts implantation and pregnancy is not clear; however, many theories exist. The rationale behind treatment of hydrosalpinx prior to IVF is to eliminate the detrimental effect of hydrosalpingel fluid either by removing the fallopian tube (salpingectomy) or by isolating it from the uterine cavity (laparoscopic or hysteroscopic occlusion, or Essure insert), or by aspirating the hydrosalpingel fluid (ultrasound-guided). Keywords: Hydrosalpinx, IVF 1. INTRODUCTION Hydrosalpingel fluid may contain inflammatory mediators such as cytokines, prostaglandins, and Tubal factor infertility accounts for up to 35% mucosal debris that may be toxic to the of female infertility, and was one of the original motivations for the development of in-vitro implanting embryo [6]. fertilization (IVF) [1]. The presence of hydrosalpingel fluid in the Hydrosalpinx is defined as fluid collection in a endometrial cavity physically inhibits blocked fallopian tube, and is found in about 10- implantation and impairs the expression of 30% of women with tubal factor infertility, factors essential for the development and corresponding to approximately 5% of infertile differentiation of the endometrium, such as women [2]. integrins (the best endometrial receptivity markers) [7]. Hydrosalpinx is associated with a large redu ction in pregnancy rates following IVF Hydrosalpinx may be also associated with impaired endometrial and ovarian blood flows (about 40-50%), and an increased risk of miscarriage and ectopic pregnancy [3]. which may adversely affect endometrial receptivity and oocyte quality [8]. This review discusses the effect of hydrosalpinx on IVF and the lines of management of 2.2. Management of Hydrosalpinx before IVF hydrosalpinx before IVF. The rationale behind treatment of hydrosalpinx 2. DISCUSSION prior to IVF is to eliminate the detrimental effect of hydrosalpingel fluid either by 2.1. Effect of Hydrosalpinx on IVF removing the fallopian tube (salpingectomy) or Patients with a hydrosalpinx have been found to by isolating it from the uterine cavity have significantly poorer IVF outcome than do (laparoscopic or hysteroscopic occlusion, or patients with tubal factor infertility but no Essure insert), or by aspirating the hydrosalpinx [4]. hydrosalpingel fluid (ultrasound-guided) [9]. The exact mechanism by which hydrosalpingial Laparoscopic surgery, including salpingectomy fluid impacts implantation and pregnancy is not or tubal occlusion, has been shown to improve clear; however, many theories exist. IVF outcome for patients with a hydrosalpinx The harmful effect of a hydrosalpinx on [10]. However, this procedure has many pregnancy after IVF has been attributed to drawbacks, including its invasiveness, technical mechanical washout of the transferred embryos difficulty if there are pelvic adhesions, the by tubal-uterine reflux of the hydrosalpingel possibility of surgical injury (e.g. visceral fluid [5]. injury, vascular damage, or unintended ARC Journal of Gynecology and Obstetrics Page | 21 Hydrosalpinx and IVF: Effect and Management laparotomy), and the potential risks from ─ Evidence is insufficient to allow assessment general anesthesia [11]. of the value of aspiration of hydrosalpinges before or during IVF procedures (very low- There are also some concerns about quality evidence) or the value of tubal salpingectomy, including its potentially negative restorative surgery as an alternative (or as effect on the ovarian blood flow and subsequent apreliminary) to IVF. reduction of ovarian response to gonadotropin stimulation, and its permanent nature, which REFERENCES precludes any possibility of spontaneous [1] Strandell A, Lindhard A,WaldenströmU, conception in the future in cases of bilateral Thorburn J. Hydrosalpinx and IVF outcome: salpingectomy [12]. cumulative results after salpingectomy in a Proximal tubal occlusion of a hydrosalpinx by randomized controlled trial. Hum Reprod. 2001; 16(11): 2403-10. hysteroscopy (either an Essure insert or electrocoagulation) might offer a feasible [2] D'Arpe S, Franceschetti S, Caccetta J, Pietrangeli D, Muzii L1, Panici PB. therapeutic alternative when laparoscopy is Management of hydrosalpinx before IVF: a technically difficult or contraindicated [13]. literature review. J Obstet Gynaecol. 2015; Although an Essure device is an effective 35(6): 547-50. method for sterilization, there is some [3] Practice Committee of American Society for apprehension regarding its use in the treatment Reproductive Medicine in collaboration with of a hydrosalpinx before IVF. In addition to the Society of Reproductive Surgeons. Salpingectomy for hydrosalpinx prior to in cost of the device, the Essure coil might trail vitro fertilization. Fertil Steril. 2008; 90(Suppl. into the uterine cavity, with possible effects on 5): S66-8. both implantation and pregnancy, and the nickel [4] Puttemans P, Campo R, Gordts S, Brosens I. titanium elastic outer coil might affect the Hydrosalpinx and ART: hydrosalpinx— developing embryo [14-16]. functional surgery or salpingectomy? Hum Hysteroscopic tubal electrocoagulation might be Reprod. 2000; 15(7): 1427-30. a possible alternative to the Essure device for [5] Mijatovic V, Veersema S, Emanuel MH, Schats hydrosalpinx treatment before IVF. However, R, Hompes PG. Essure hysteroscopic tubal occlusion device for the treatment of hysteroscopic monopolar surgery is associated hydrosalpinx prior to in vitro fertilization- with both the potential risk of electrosurgical embryo transfer in patients with a injury and complications of distending media contraindication for laparoscopy. Fertil Steril. [17, 18]. 2010; 93(4): 1338-42. Aspiration of hydrosalpingel fluid is less [6] Koong MK, Jun JH, Song SJ, Lee HJ, Song IO, invasive and easier to perform in cases of dense Kang IS. A second look at the embryotoxicity pelvic adhesions. However, its main of hydrosalpingeal fluid: an in-vitro assessment in a murine model. Hum Reprod. 1998; 13(10): disadvantages are the high recurrence rate of 2852-6. hydrosalpinx and the possibility to flare up [7] Savaris RF, Pedrini JL, Flores R, Fabris G, pelvic infections [19]. Zettler CG. Expression of α1 and β3 integrins 3. CONCLUSION subunits in the endometrium of patients with tubal phimosis or hydrosalpinx. Fertil Steril. A recent overview of Cochrane reviews [20] 2006; 85(1): 188-92. concluded that: [8] El-Mazny A, Ramadan W, Kamel A, Gad- ─ Surgical treatment should be considered for Allah S. Effect of hydrosalpinx on uterine and all women with hydrosalpinges before IVF ovarian hemodynamics in women with tubal factor infertility. Eur J Obstet Gynecol Reprod treatment. Biol. 2016; 199: 55-9 ─ Both laparoscopic salpingectomy and tubal [9] Johnson N, van Voorst S, Sowter MC, Strandell occlusion before IVF increase the chances of A, Mol BW. Surgical treatment for tubal clinical pregnancy (moderate-quality disease in women due to undergo in vitro evidence). fertilisation. Cochrane Database Syst Rev. 2010; 1: CD002125. ─ Laparoscopic tubal occlusion is an alternative [10] Johnson NP, MakW, Sowter MC. Surgical to laparoscopic salpingectomy for improving treatment for tubal disease in women due to pregnancy rates among women with undergo in vitro fertilisation. Cochrane hydrosalpinges undergoing IVF. Database Syst Rev. 2004; 3: CD002125. ARC Journal of Gynecology and Obstetrics Page | 22 Hydrosalpinx and IVF: Effect and Management [11] Practice Committee of the American Society in vitro fertilization. Fertil Steril. 2007; for Reproductive Medicine. Salpingectomy for 88(Suppl. 1): S16. hydrosalpinx prior to in vitro fertilization. Fertil [17] Aboulghar MM, Azmy O, Nada A, Shawky O, Steril. 2004; 82(Suppl. 1): S117-9. Mostafa H. Hysteroscopic tubal [12] Orvieto R, Saar-Ryss B, Morgante G, Gemer O, electrocoagulation in cases with Anteby EY, Meltcer S. Does salpingectomy communicating hydrosalpinx and planning for affect the ipsilateral ovarian response to IVF—a pilot study. Int J Med. 2008; 1(2): 81-5. gonadotropin during in vitro fertilization-embryo transfer cycles? Fertil Steril. 2011; 95(5):1842-4. [18] El-Mazny A, Abou-Salem N, Hammam M, Saber W. Hysteroscopic tubal [13] Ozgur K, Bulut H, Berkkanoglu M, Coetzee K, electrocoagulation versus laparoscopic tubal Kaya G. ICSI pregnancy outcomes following ligation for patients with hydrosalpinges hysteroscopic placement of Essure devices for undergoing in vitro fertilization. Int J Gynaecol hydrosalpinx in laparoscopic contraindicated patients. Reprod Biomed Online. 2014; 29(1): Obstet. 2015; 130(3): 250-2 113-8. [19] Hammadieh N, Coomarasamy A, Ola B, [14] Kerin JF, Cattanach S. Successful pregnancy Papaioannou S, Afnan M, Sharif K. outcome with the use of in vitro fertilization Ultrasound-guided hydrosalpinx aspiration after Essure hysteroscopic sterilization. Fertil during oocyte collection improves pregnancy Steril. 2007; 87(5):